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In addition, the information submitted may become a part of your patient’s permanent chart or treatment record at The Emily Program upon his or her utilization of The Emily Program services and this information may be used in the planning of treatment and care provided to your patient. At the time your patient utilizes The Emily Program’s services, The Emily Program’s Notice of Privacy Practices, other HIPAA and information privacy and security policies will apply to the information submitted on this form and to any other information that The Emily Program maintains about your patient and the care provided to your patient.